MEDICARE: SUSAN W ETTINGER MSN,NPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	279604	MA
2	363L00000X	Nurse Practitioner	R078653	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144325275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN W ETTINGER MSN,NPC

Provider Business Mailing Address
First Line	:	6201 GREENLEIGH AVE
Second Line	:
City	:	MIDDLE RIVER
State	:	MD
Zip	:	21220-2004
Country	:	US
Telephone Number	:	410-933-5412
Fax Number	:

Provider Business Practice Location Address
First Line	:	2360 W JOPPA RD
Second Line	:
City	:	LUTHERVILLE TIMONIUM
State	:	MD
Zip	:	21093-4624
Country	:	US
Telephone Number	:	410-847-3535
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	02/05/2024

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